Saturday, October 31, 2009

House: Creates government-run health-insurance plan that would negotiate rates with doctors and hospitals.

Senate: Same except states would have right to opt out.

Winners/Losers: This could be a good thing for doctors. Doctors likely to get higher payments than they would if public plan rates were tied to Medicare. Insurers could lose because they'll face a new competitor, with whom losses and profit are no object.

Employer Mandate

House: Employers must provide health-insurance coverage or pay fine of 8% of payroll (for those with payroll greater than $750,000).

Senate: Penalty for employers who don't provide coverage is up to $750 per employee, if employees get government subsidies.

As I watch the Washington health reform merry-go-round, where it stops no one knows, four never-nevers among the D.C. elite spring to mind.

One, health care reform is too important to be left to patients or health care consumers. Goodness knows, patients might make the wrong decision, they might forego preventative tests, they might trust the decision of a physician, who knows even less than they do about health care, and who has incentives to do more rather than less for personal enrichment. Never, never let patients or health consumers judge what is good for their health or their sickness. Never let them pick or own their own health plan across state lines, one suited for their needs, or related to their present health status. The Will of Congress, not the Will of the People is what counts.

Two, health care reform is far too important to be left to the clinical judgment of experienced physicians. Everybody knows physicians don’t have results from a national database on the comparative effectiveness of treatments they recommend. Doctors are too specialized, might recommend what they do well, and be paid for what they do. Heaven forbid, they might be paid on a fee-for-service rather than a salaried basis. Don't try to rebuild our primary care base. These doctors are too close to patients. Their desire to please patients and meet their expectations and those of their families is too anecdotal, personal, and emotional in this data-driven age. Never, never let individual doctors serve as trusted advisors to individual patients. Neither patients or their doctors, separately or together, know as much at decision-makers in D.C., who stand for the common good, not the individual good.

Three, never let talk of money or costs of care enter into the patient or doctor equation. Comprehensive health care is a free entitlement, a right, and should be devoid of financial considerations. A patient should never have to ask, “ What does this cost” Or “What will be my personal financial obligation?” And goodness me, never have to ask, “What does this cost my employer?” Take it for granted, access to comprehensive care without limits is a given. Somehow the “system,” rather than common sense of people receiving and delivering care, will provide for you. Never take into account that money you save from doctor or hospital shopping might be money saved for your retirement. If you’re a doctor, never ask what the drug you’re prescribing or the treatment you’re recommending, might cost at the local pharmacy or local hospital, or what the low cost alternatives might cost.

Four, never question the judgment of Congressmen or Senators. Yes, these politicians have 3300 lobbyists - six for every Congressman or Senator - lobbing special interest money at each and everyone. Yes, they are weighing pros and cons of getting elected. Yes, they are weighing the effects of government-directed public options, employer mandates, increased taxes on providers and the middle class , and individual and employer mandates on the uninsured and businesses on the national debt, unemployment, the economy, but they are not influenced by any of these factors. Politicians are elitists with detached objective, and repositories of collective wisdom not known to common folk. Their historical legacy of bringing health care to all moves them most, no matter what the possible adverse consequences on patients and doctors, or how to pay for it all. Trust Congress. They are from the government.

Friday, October 30, 2009

Melodies bring memoriesThat linger in my heart Make me think of GeorgiaWhy did we ever part?Some sweet day when blossoms fall And all the world's a songI'll go back to Georgia'Cause that's where I belong.Georgia, Georgia, the whole day through Just an old sweet song keeps Georgia on my mind. Georgia, Georgia, a song of youComes as sweet and clear as moonlight through the pines.Other arms reach out to me Other eyes smile tenderlyStill in peaceful dreams I see The road leads back to you.Georgia, Georgia, no peace I find Just an old sweet song keeps Georgia on my mind.

Song, Georgia on My Mind

I have always had a soft spot in my heart for Georgia. This is partly because I was raised in neighboring Tennessee. And it is partly because the Medical Association of Georgia had the fortitude and foresight to sponsor a study indicating private practice positively impacted the general economy rather than being a negative drag, the position of the Obama administration (see November 6, 2008, medinnovation blog, “Economic Impact of Private Practice in Georgia.” In more recent years, as the health reform debate has evolved, and particularly now, as its reaches its flash point, I like Georgia even more.

Why? Because you always know where the doctors of Georgia stand. You don’t have to agree with them, but you know where they stand. For example, 79% of them stand against a public option, and 72% stand against an individual mandate.

And, as I read the statement of M. Todd Williamson, MD, an Atlanta neurologist and immediate past president of the Medical Association of Georgia before the GOP Doctors Caucus in Congress on October 28, it becomes clear Georgia doctors stand against any government involvement or intervention into doctor-patient decision making.

In making his statement, Dr. Williamson represented the Coalition of State and Specialty Medical Societies, made up of 50,000 practicing physicians and two past presidents of the AMA – Donald J. Palmisano, MD, AMA President, 2003-2004, and William G. Plested, III, AMA President, 2006-2007.

In the words of Dr. Williamson, “There is no place for government in our exam rooms.” When patients ask what Georgia doctors think of current health reform bills, Doctor Williamson says, “We tell them we reject the premise that increased government involvement in the delivery of care is good for them or our profession.” But he adds, “Unfortunately, increased government involvement is our patient’s health care forms the basis of all of the bills that are currently making their way through Congress.”

Georgia physicians stand for.

• patients being able to spend their own tax-free money on their own medical care;

• patients being able to own and control their health insurance regardless of their employment status,;

• government adequately funding Medicare and Medicaid, for tort reform with a cap on non-economic damages;

• removing the government and third parties from the patient-physician relationship;

• not using comparative effective research as a rationing tool, and for fixing the SGR (Sustainable Growth Rate) formula as a basis for paying physicians. Of SRG cuts of 21.5% go into effect this year, Dr. Williamson says, “Our seniors will fact an unprecedented loss of access to medical care because doctors will be unable to continue to treat seniors.”

Accompanying Dr. Williamson’s statement were letters to Nancy Pelosi, and to Max Baucus and Charles Grassley.

In the Pelosi letter, the Coalition set forth these principles on a patient-centered health system.

1. Choice of Health Plan

2. Choice of Physician

3. The Right to Privately Contract

4. The Right of Physician to Determine Quality Care.

And they “adamantly” opposes: 1) The Public Options; and 2) Individual and Employee Mandates.

In the Baucus –Grassley letter, the Coalition expresses “concern” over.

1. Government mandates requiring individuals being required to purchase health insurance or face penalties, standardized health insurance benefits, physicians being required to participate in quality reporting or face a Medicare cut of2%; and the establishment national bench marks for resource use with cuts of 5% of those exceeding this use.

2. The temporary- one year SRG patch to replace the Medicare 21.5% cut with a 0.5% increase in 2010.

5. The lack of any language about the ability of doctors and patients to privately contract without penalty.

I am proud a leader of the Medical Association of Georgia, representing the Coalition of State and Specialty Medical Societies, is taking a lead for physicians' stands on health reform, which have received scant attention in Obamacare circles and in the national media.

Thursday, October 29, 2009

Soak the Rich, Tax all those making $250,00 or more and a surtax on individuals making over $500,000 and couples making over $1 million.

Soak the Young, by mandating them to pay the same premiums as the Old or else pay the Federal Piper in the form of the IRS.

Soak the Old, Medicare recipients, by cutting $500 billion in benefits over the next ten years.

Soak Business, by mandating them to cover all workers, or pay stiff fines.

Soak Holders of “Cadillac” health plans, more than 100 million Americans, many of hem union members, who pay more than $8,000 as individuals or $21,000 as families, by slapping an excise tax on them.Soak Health Plans, by forcing them to accept those with pre-existing illnesses, thereby driving up premium and threatening to remove their anti-trust exemptions.

Soak All Those Evil-Doers, Those Profit-Making Members of the “Medical Industrial Complex” by willy-nilly imposing high taxes on them.

Soak Entrepreneurs and Innovators, by strangling them with rules and regulations.

Soak States by burdening them with the uninsured and expanding Medicaid, which they cannot afford now.

Soak Doctors by fixing their Medicare pay at current levels for the next ten years.

Soak Medical Practices by punishing them by paying them less if they do not install unproven Electronic Medical Records.

Soak hospitals and doctors by introducing a public option that will ultimately pay them at Medicare rates, now 30% lower on average than private rates.

Soak busy primary care physicians who care for the chronically ill by cutting their pay if their expenses place them in the 90 percentile of Medicare expense generators.

Soak the Gullible by taxing and fining providers immediately but suspending benefits for the uninsured and the working poor and moderate income Americans until 2013.

Soak American taxpayers by saying by declaring that hypothetical savings from electronic medical records, prevention, comprehensive chronic disease coordination, and stamping out $60 billion from Medicare fraud and abuse, comparative research findings, and various payment reforms imposed by various “commissions” will make it possible to add “not one dime” to the federal budget even if historically the federal government has never saved a dime in entitlement programs.

Soak it to them!

Soak it to them in the name of “ greater affordability” and “increased access” even if many providers and middle class Americans won’t be able to afford higher premiums and doctors can't afford to do so or won’t be there or will decline to be there to provide the care.

Take it from this old bloke, when you set out to soak, do it in one fell swoop, do it with a loud political whoop, do it with mirrors, and smoke, and conceal it with protestations of good intentiones.

Soak it to them for the common good - and for our political power. Everybody has to make sacrifices for us, for we know what is good for you.

Wednesday, October 28, 2009

I find it fascinating to read the different health reform views of economists in academia and mainstream Republicans. When I think of the academics, professors Uwe Reinhart and Paul Krugman of Princeton and Alain Enthoven and Victor Fuchs of Stanford, spring to mind. Various vocal Republicans Senators and Congressmen, come to the surface. Their names are too numerous to mention because they stand united against current reform plans.

According to David Horowitz in the The Professors: the 101 Most Dangerous Academics in America in one way or another, most university professors are Democrats and are overwhelmingly “leftists” (The Professors, Regnery Publishing, 2006). Horowitz focuses on radicals, which I'm sure is not universally the case. But certainly most academics who write on health reform favor more government control and more “top-down” management while the Republican party leans towards market reforms.

Victor Fuchs, PhD, professor emeritus of health economics at Stanford, now 85, has been writing on health economics for 40 years.His classic Who Shall Live? Health Economics and Social Choice (Basic Books) appeared in 1974. In the October 29 NEJM, he offers four choices he favors for health reform.

1) creation of insurance exchanges, similar to the Federal Employees Health Benefit Program (FEHBP), and the California Public Employees Retirement System (CalPERS).

2) elimination or limitation of the tax exception of employer-based health insurance with the ultimate goal of doing away with this type of insurance altogether.

3) appointment of an expert commission to devise changes to the way Medicare pays providers.

4) federal funding for a quasi-independent institute for technologic assessment.

And as a fifth choice, almost as an afterthought, he advocates universal coverage financed by a value-added tax dedicated to providing basic coverage for all.

These choices would require more government, phasing out of an employer-based system, and less independence of physicians, which are not Republican positions.

In spite of frequent accusations of being the "No" party on reform Republicans have introduced 6 plans this year. These 6 plans contain these basic elements.

1. Permit insurers to sell policies across state lines.

2. Give people who buy insurance in the private market the same tax breaks as those who get it through employers. People who want to buy insurance in the individual market should get the same tax breaks as employers. That would help millions of people acquire coverage.

3. Expand the ability of small businesses, trade associations and other groups to set up insurance pools to offer coverage at more attractive rates.

4. Enact tort reform and control health costs in part by reining in the medical malpractice system that raises insurance premiums and forces doctors to order tests to protect themselves from lawsuits.

There are a few, but only a few, commonalities between the academics and the Republicans - reforming the employer based system and setting up insurance exchanges or insurance pools to create competition and lower rates.

Republican plans would cost taxpayers much less, perhaps half of what the academics propose, but would expand coverage indirectly rather than directly, through tax write-offs for all health care benefits, whether one is employed or not, and would not guarantee coverage for all. And, of course, the academics rarely mention tort reform.

Perhaps the biggest differences is that the academics would have a government-based “expert” commission to reform doctor pay , a “quasi-commission” to evaluate new technologies, employer and individual mandates, and even a Value-Added Tax (VAT) to guarantee universal coverage. A VAT is anathema to Republicans, an example of government run amuck. The differences hinge on a “top-down” versus a “bottom-up” approach. It’s the fundamental problem of the “center-left” dictating to the “center-right.”

From present reform difficulties, Professor Fuchs concludes,

"Prospects for th enactment of some reform look good, but comprehensive sustainable reform of the health care system must wait for another day. Republican support for President Obama's ambitious agenda is fading fast. As imaginative truly bipartisan approach has failed to gain any traction. Within the Democratic majority, sharp disagreements in each house, and between the House and the Senate, do not augur well for coherent legislation."

As for me as I write, I am reading Dumas Malone's 1962 book Jefferson and the Ordeal of Liberty. Thomas Jefferson was the original Republican and consistently argued for more individual liberties and less government.

From this book and from what I observe on the current scene, I conclude,

When and where the good of society, individual liberties, and good intentions intersect, conflict is inevitable and necessary to reach common ground. In my view, it is possible to disagree agreeably, to listen respectfully to each other's point of view without rancor, racism, and radicalism, and for both to be right, each in their own way, each from their own vantage point, each for the right reasons. That's what makes for good suasage - intellectually seasoned, but edible for most of the people most of the time, with room for individual liberties.

A Hypothetical Example of Disruptive Innovation and Predictive Modeling

Running is not an innocuous activity, even for veteran runners. Running does not convey immortality on its practitioners. Jim Fixx, author of The Complete Book of Running, died at 52 while running, and Dr. Richard Lillihei, a surgeon and fitness expert, dropped at 53 while running.

In the half Detroit Marathon recently, in which 8500 runners participated, three runners, all males, 65, 36, and 26, dropped dead. Earlier in the year, single deaths occurred in young man and young woman in their thirties in San Jose and in a 23 year male Virginia Beach halfmarathons. In the upcoming New York City marathon, the world’s largest, more than 100,000 runners will compete. Odds are, one or two of them won’t make it to the finish line because of sudden death.

In 2008 in the U.S, 425,000 ran in full marathons, and 745,000 in half marathons. Each year 4 to six marathon runners will collapse and die. Last year 7 died. The odds are 0.8 deaths per 100,000.

Could these deaths be predicted using disruptive innovation and predictive modeling? Disruptive innovation is offering specialized care in decentralized settings. Predictive modeling is a process by which a model is created to predict the probable outcome of something.

In the case of coronary artery disease, the usual cause of sudden death among runners, a clinical database of hundreds of thousands of people who have undergone cardiac stress testing is used to predict hospitalization or sudden death, given a set of known physiological variables.

According to the developers of SHAPE (System of Heart and Pulmonary Evaluation) medical systems, of St. Paul, Minnesota, the presence of early or advanced coronary artery disease can precisely be detected within a span of 6 minutes by using a simple portable SHAPE device – consisting of an electrocardiogram, a one step staircase, a snorkel like mouthpiece, a gas exchange analyzer, and a laptop containing a large database of previous individual who have undergone testing and whose clinical outcomes are known.

This testing has no risk since minimal exercise, stepping up and down on a staircase, or a six minute walk, is the only preparation. The SHAPE equipment is mobile, doesn’t require the presence of a cardiologist, and could easily be set up to test runners prior to a marathon or at the marathon site.

This is just a thought. To my knowledge, SHAPE has not been deployed before any marathon. But SHAPE lends itself to testing those to whom fitness is important, as personified by marathon runners.

For more information on SHAPE, see www.shapemedicalsystems.com and these previous medinnovation blogs, July 24, 2009, “Testing for Cardiopulmonary Insufficiency in the General Population”, July 14, 2009, “Eureka! Measuring Physician Fitness to Bridge Gap Between Wellness and Sickness Systems of Care,” July 7, 2009, “A Treadmill Death”; June 1, 2008, “The 35th Innovation: Back of Track,” May 16, 2009,“Evidence Based Care,” The SHAPE of Things to Come,” April 28, 2009, “How to Contain the Coronary Artery Pandemic,” June 15, 2008, “Thoughts About Tim Russert and Heart Disease.” May 6, 2007.”On Preventing Heart and Lung Disease at the Same Time.”

Tuesday, October 27, 2009

October 27 - Today I received the brochure of the 7th Annual World Health Care Congress. The Congress divides the medical world into 5 categories.

1) Employer incentives for prevention and improved productivity

2) New models for health plan, hospital, and health system collaboration

3) Implications of health reform on all sectors of health care

4) Meaningful use and deployment of Health IT

5) Disruptive Innovations and new business models and new business models in health care

Disruptive innovation speakers include Clayton Christensen, PhD, of Harvard Business School, Alfred Spector of Google, Inc, and Mohammed Yunus of Grameen Health. The latter won the Nobel Peace Prize for making tiny loans to the poor in Bangladesh to promote entrepreneurship in villagers.

These speakers champion promoting change among care users and consumers at the grassroots, a concept with which I agree.

But how can one predict what changes will succeed? It is a question that vexes venture capitalists. They want to invest in health care startups, but aren’t sure which early ventures will succeed and which will fail.

Two days ago, I wrote a blog “Disruptive Innovation, For the Alliterative.” I explained, tongue-in-cheek, that disruptive innovation in health care could be defined as,

“Disruptive innovation is defined as delegating, designating, distributing and decentralizing doctor duties and devices to decrease dollars and diminish delays in downscale destinations deployed by deliverers of care.”

I promptly received an email from Thomas Thurston, president and managing director of Growth Science International of Portland, Oregon. He said he had worked as a fellow for Clayton Christensen at Harvard Business in 2007 and 2008, and in his present position, had worked out a scheme for identifying those health care startups that were likely to succeed or fail.

Thurston divided startups into affiliated with established or sustaining firms, “incumbents,” and those that were independent startups with low cost approaches, which he deemed as “disruptive.”

To my surprise, he said the disruptive startups were more likely to succeed, perhaps because they had no cultural hang-ups connected with established firm’s cultures.

He recommended I take a look at Whiteglove House Calls in Austin, Texas. This firm offers routine medical care at home or work, 365 days a year, 8AM to 8PM, with fixed fees, including medical care, generic drugs, foods, beverages, and over the counter medications.

Furthermore, Whiteglove asserts, “Our team of physicians and nurse practitioners are committed to changing the way you are treated. We offer an alternative to expensive emergency room and urgent care centers for routine care and provide a refreshing health care experience over the hassles and inconveniences of running to the doctor, waiting, running to the pharmacy, waiting, and running to the grocery store – all before you can begin to mend. For more information, please visit www.whiteglove.com.”

I cannot vouch for Whiteglove, except to note it has expanded to other major Texas cities, and is covered by some health plans in Texas. I can also say this is a good example of “disruptive innovation” and decentralization at work.

As I noted in my previous blog, Disruptive innovation enables people to do sophisticated things in a more convenient, lower-cost setting, which historically could only be done by specialists in a less convenient setting.

Monday, October 26, 2009

Preface: President Reagan was fond of telling the story of a boy buried in a pile of manure. The boy popped his head out of the pile, and with a broad smile exclaimed, “There’s got to be a pony in here somewhere. “ Likewise, there’s got to be a pony in Senator Harry Reid’s Senate health reform proposal, but where is it? Here, Dr. Scott Altas, professor and chief of neuroradiology at Stanford University Medical Center and a senior fellow of the Hoover Institution at the university, in a Sunday, October 25 , Washington Time’s commentary, looks in vain for the pony.

Where's the Benefit?

By Scott W. Atlas. MD

“Despite all that, most Americans want reforms to bring costs down if they maintain quality.

"So our president and his Democratic allies - possibly in another teaching moment - filled our news media and Congressional Budget Office with a pile of proposals. And because Americans are optimistic, we jumped in and started digging through the pile, even though that pile looked and smelled like manure. But we figured that with all that manure, there had to be a pony in there somewhere.

"We kept digging through the Democrat proposals in search of the pony. But there was no pony.

"The Max Baucus plan is paid by massive taxes on existing insurance plans that exceed our government's arbitrary threshold and by significant cuts to Medicare. Its Federal Exchange overtly skews the playing field by subsidizing - directly or indirectly - insurance plans that meet government definitions, and by penalizing existing plans that don't, plans already held by millions of Americans. The House proposals force a government-run "public option" - an option that shifts huge numbers of privately insured Americans to become the burden of an already unsustainable, taxpayer-funded entitlement program that ultimately eliminates private insurance choices.

"A public option would interpose bureaucrats between doctors and patients, restricting access to new drugs, to innovative new cures, and to choice of doctors.

"It is already proven a failure the world over, even by our own Medicaid program, where government-imposed, below-cost payments have created patients who cannot even find doctors to care for them. While Congress and the administration claim otherwise, costs to the taxpayer increase, and choice and access disappear with a public option.

"Meanwhile, serious alternative solutions that reduce costs but do not harm the excellence already in our health system are totally ignored, including:

• Allowing people to shop for insurance across state lines at competitive prices.

• Stripping back on costly coverage mandates that most Americans may not value, like acupuncture, massage therapy, in vitro fertilization, and wigs.

• Expanding the availability of high-deductible plans for catastrophic coverage with health savings accounts, making insurance a good value for the millions of Americans who can afford insurance but (perhaps wisely) don't buy it.

• Bold tax reforms like refundable tax credits, cash even for those who pay no income tax, or vouchers instead of tax deductions, to foster personal ownership and control of insurance, creating millions of value-seeking shoppers.

• Forcing doctors and hospitals to post prices, qualifications and outcomes - information that is essential to value-based purchasing and fundamental for stimulating competition.

"The American public is beginning to see the threat. We see their emotional displays at town halls, individuals trying to preserve some of the most personal and important decisions in their lives.

"Americans who value control of their own health decisions, access to sub-specialty doctors of their own choosing, and access to safer, more effective treatments are beginning to recognize what they are about to lose. America's health system, the most advanced in the world, is about to be destroyed, and most of the debate is about how to pay for it.

"The unspoken truth is that the president and the Democratic Congress are fundamentally wrong about their radical plans for health reform. And even a speaker as articulate and persistent as this president - holding a monopoly of congressional power, and despite all the repetition, the distortions and the deceptive rhetoric.”

Medicare Fraud is a $60 billion industry for criminals, who find Medicare “easy” to rip off using fake storefront addresses and using stolen medicare patient information

Prelude: October 26 - According to a CBS “60 Minutes” report last night, which I reproduce below. Medicare now spends $430 billion a year. Of this, $60 billion, or 14%, flows to criminals operating out of unoccupied store fronts with addresses and using Medicare information stolen from hospitals, drug stores, doctors’ offices, and patients themselves.

This is frightening. The public option, after all, may be nothing but a ploy to extend Medicare to all. Medicare prides itself on paying claims within 30 days without intervening based on provider and patient claims information. Yet Medicare is no model for reform. In a September 11 WSJ article Grace-Marie Turner, president of the Galen Institute, and Joseph Antos, senior fellow at the American Enterprise Institute, give 5 reasons why Medicare is a failed model:

1) Medicare is going bankrupt;

2) Private payers are bailing out hospitals and doctors, keeping them in business despite 30% lower Medicare payments;

4) Low Medicare administration costs are a mirage and fantasy and don not reflect true costs;

5) Medicare is rife with fraud;

6) Medicare shortchanges seniors by exposing them to unmanageable costs;

7) Medicare business model is obsolete and contains no innovations for disease management or wellness and prevention;

8) Medicare payments are too low, and many doctors are not accepting new Medicare patients;

9) Medicare decisions are being made in Washington by nonmedical bureaucrats;

10) No one is running show’ Obama administrations has yet to name an administrator for Centers of Medicare and Medicaid, which cover over 100 million Americans. Criminals are aware of the ease with which a headless Medicare administration can be ripped off, and are moving accordingly. The following should be required reading for those who support a government run public option.

Medicare Fraud: A $60 Billion Crime CBS 60 Minutes, October 25, 2009

STEVE KROFT, CBS: Of all the problems facing the United States right now, none are more important than healthcare. President Obama says rising costs are driving huge federal budget deficits that imperil our future, and that there is enough waste and fraud in the system to pay for health care reform if it was eliminated.

At the center of both issues is Medicare, the government insurance program that provides health care to 46 million elderly and disabled Americans. But it also provides a rich and steady income stream for criminals who are constantly finding new ways to steal a sizable chunk of the half a trillion dollars that are paid out each year in Medicare benefits.

In fact, Medicare fraud - estimated now to total about $60 billion a year - has become one of, if not the most profitable crimes in America.

We caution you that this story may raise your blood pressure, along with some troubling questions about our government's ability to manage a medical bureaucracy.Kroft spoke with FBI special agent Brian Waterman and Kirk Ogrosky, a top justice department prosecutor:

BRIAN WATERMAN, FBI: There's a healthcare fraud industry where people do nothing but recruit patients, get patient lists, find doctors, look on the Internet, find different scams. There are entire groups and entire organizations of people that are dedicated to nothing but committing fraud, finding a better way to steal from Medicare

KROFT: Is the Medicare fraud business bigger than the drug business in Miami now?

KIRK OGROSKY, JUSTICE DEPARTMENT: I think it's way bigger.

KROFT: What changed?

OGROSKY: The criminals changed...

WATERMAN: Sophistication.

OGROSKY: They've figured out that rather than stealing $100,000 or $200,000, they can steal $100 million. We have seen cases in the last six, eight months that involve a couple of guys that if they weren't stealing from Medicare might be stealing your car.

WATERMAN: You know, we were the king of the drugs in the '80s. We're king of healthcare fraud in the '90s and the 2000's.

Kroft also spoke to Attorney General Eric Holder:

ERIC HOLDER, ATTORNEY GENERAL: We have to understand this is a major fraud area.

KROFT: Why do you think it's been so attractive for the criminals?

HOLDER: Because I think it's been pretty easy. I think that they have found a way in which they have been able to get pretty substantial amounts of money with not a huge amount of effort and at least until now, without the possibility of great detection.

KROFT: With much fewer risks.

HOLDER: Much fewer risks. You'll see some of these people and they'll say "You know there is not a chance that you are going to have some other drug dealer shooting at you." The chances of being incarcerated were lower, the amount of time that you would spend in jail was smaller. All of which is different now.

Kroft then spoke to a man who claimed to have defrauded Medicare out of $20 million, after which Kroft said, "According to the FBI, all you have to do to get into this business is rent a cheap storefront office, find or create a front man to get an occupational license, bribe a doctor or forge a prescription pad, and obtain the names and ID numbers of legitimate Medicare patients you can bill the phony charges to."

WATERMAN: There's a whole industry of people out there that do nothing but provide patients.

Kroft narrated, "Once the crooked companies get hold of the patient lists, usually stolen from doctors' offices or hospitals, they begin running up all sorts of outlandish charges and submit them to Medicare for payment, knowing full well that the agency is required by law to pay the claims within 15 to 30 days, and that it has only enough auditors to check a tiny fraction of the charges to see if they are legitimate."

Later, Kroft asked Waterman, "There's something I don't understand. I mean, you're saying essentially people just fill out the phony paperwork, they send a bill to Medicare and they pay it."

WATERMAN: That's why you have companies that can run for 60, 90 days, and bill for ridiculous things. Because there are very few checks and balances to even determine whether these things a, were medically necessary, b, were ever given, or c, even physically possible for a patient with the kind of conditions they have.

A bit later in the segment, Kroft spoke with Kim Brandt, Medicare's director of program integrity. After he shared with her some of the scams he'd previously witnessed or been told about, he asked how crooks get away with it:

KIM BRANDT, MEDICARE DIRECTOR: We're as frustrated by that as the law enforcement officials that you went out with. And in fact, our primary focus over the past years has been to tighten our enrollment standards to make it so it's much harder for people like that to be able to get in the program, and to be able to commit that kind of fraud.

KROFT: Look, I'm sure that you're aware of these problems. But it doesn't seem like you're doing a very good job. I don't mean you personally, but I mean, the government. This is still like a huge problem, and getting worse, right?

BRANDT: Well, it really does come down to the size and scope of the Medicare program, and the resources that are dedicated to oversight and anti-fraud work. One of our biggest challenges has been that we have a program that pays out over a billion claims a year, over $430 billion, and our oversight budget has been extremely limited.

Just imagine what the fraud will be like if the government is responsible for everyone's healthcare.

As the segment drew to a close, Holder told Kroft something that should scare the heck out of everyone who wants government run insurance for all Americans: "I think people I don't think necessarily thought that something as well intentioned as Medicare and Medicaid would necessarily attract fraudsters. But I think we have to understand that it certainly has."

Sunday, October 25, 2009

Disruption enables less-skilled people to do more sophisticated things. Disruptive innovation enables a large population of less-skilled population to do things in a more convenient, lower-cost setting, which historically could only be done by specialists in a less convenient setting.Clayton Christensen, Harvard Business School, Disruptive Innovation in Health Care, January 2008

October 25 – This morning’s news is that health costs will rise 15% for small businesses. Brokers and analysts trace this sharp increase to insurers anticipating Obamacare’s impact on earnings and profits.

This bad news raises the question: can we innovate our way out of this unsustainable rise in costs? Yes, says Clayton Christensen, a professor at Harvard Business School. He introduced the phase “disruptive innovation” into the management lexicon in 2003.

Christensen advances this proposition, “Health care hasn’t become affordable because it hasn’t gone through disruptive decentralization.” By this, he means we haven’t decentralized care down the health care chain from specialized hospitals, to community hospitals, to outpatient facilities, to doctors’ offices, to home care, to self care, nor have we transferred much care from specialists to generalists.

According to Christensen and followers, successful disruptive innovation allows less costly people using less costly approaches in decentralized settings to:

1) do the work of those in more centralized specialized settings;

2) meet the demands of consumers without asking them to change their usual ways of doing things;

3) meet the requirements of organizations and regulations;

4) to do so, by beginning small in seemingly unattractive “trivial” new ways of doing things.

As a writer and sometime poet, I’ve been thinking how I can express the concept of disruptive innovation in a more succinct, yet comprehensive and memorable way to bring it into sharper focus and to give a few examples.

Here is my alliterative definition.

Disruptive innovation is delegating, designating. distributing, and decentralizing doctor duties and devices to decrease dollars and diminish delays in downscale destinations deployed by different deliverers of care.

This is admittedly a contriveed tongue-in-cheek alliterative stretch.

Allitrative wordplay aside, the point is a lot of things in health care can be done well by nurses, nurse practitioners, physician assistants, a new group of people called “medical assistants,” patients themselves using rules-based protocols and, and doctors deploying new approaches in mobile, small, technologies, both IT and non-IT based, and new business models in downscale environments - all while preserving the role of doctors to make complex, clinical judgments their educations prepares them to make.

Some examples, some of which may seem “trivial” or "far-fetched" will suffice.

• Having nurses and physicians assistants take histories, do school physicians, collect history information, give immunizations,

I am aware I am oversimplifying, maybe even “trivializing” a subject as broad and complex as dbruptive medical innovation, which includes such things as surgical and anesthesia advances, angioplasty, outpatient surgeries, outpatient imaging, and noninvasive vascular diagnostic – most of which occur in specialized settings.

Friday, October 23, 2009

From Grace Marie Turner, President and Founder, Galen Institute. October 23, 2009So let's get this straight. Congress is planning to add at least $1 trillion to federal spending, throw 13 million seniors out of their Medicare Advantage plans, impose half a trillion dollars in new taxes, require individuals and businesses to buy health insurance that is more expensive than most can afford now -- and tax them if they don't comply -- and all of this will cause health care costs to actually go up? And we still don't get to universal coverage?

Go directly to the 1999 WHO report. It ranks U.S. 37th among health systems.Cite the report without qualifications.

Do not say it is flawed and outdated.Or that it rests on incomplete data.Or that it ignores cultural, behavioral, and economic factors,beyond the reach of health systems.

It forgets to mention dietary habits and obesity.

It does not mention the U.S. ranks first in responsiveness,on speed of access, number of choices, and quality of amenities.

It does not say 1999 data is old or full of uncertainties.

It does not say U.S. has world’s best technologies,and the best results for those with chronic disease.

Do not question single payer advocates,who keep throwing the WHO Report against the wall.

It does not bring up the fact that many European nations,now use private plans to provide universal coverage.

Above all,

never quote Philip Musgrove, editor-in-chief of 1999 WHO Report,who now says rankings contained “so many made up numbers,”and that ranking national health systems is “ a fool’s errand.”

Or, heaven forbid, do not cite Alan Garber, MD, An economist and professor of medicine at Stanford.

He talks of nutrition, education, exercise, and public safety,as prime factors just as or more important than health systems, in improving a nation’s overall health,“Not every health problem, “ he says, “has a medical solution.”

Instead, cite the 1999 WHO Report and the U.S. as the 37 Ranked System .

Source: Carl Bialik, “Ill-Conceived Ranking Makes for Unhealthy Debate In the Wrangle Over Health Care," a Low Rating for the U.S. System Keeps Emerging Despite Evident Shortcomings in Study,” Wall Street Journal, October 21, 2009.

The Wall Street Journal today carried a book review on Chaos and Organization in Health Care (MIT Press, $29.95). Its authors are Thomas H. Lee, MD, and James J. Mongan, MD. They arek respectively, the network president and chief executive of Partners Health Care, the Boston-based parent company to Brigham & Women’s Hospital and Massachusetts General Hospital, as well as empire extending to a large number of medical clinics and hospitals in Greater Boston.

Partners Health Care’s mission is to bring chaos out of health care disorder in Boston, as well as greater Massachusetts, which already has a 3 year old universal health plan, also designed to minimize chaos. This is ironic. Boston has always considered itself the Hub of Medical Care – the most organized and progressive cluster of medical centers in the nation.

Drs. Lee and Mongan admit bringing workable harmony among Boston caregivers can be difficult. Medicine, it seems, is riddled with “gray zones,” where there is no perfect therapy, given the variability of disease, patients, and doctors themselves. If this is a problem in a tightly knit organization like Partners Health Care, rampant dysfunction must exist the nation as a whole, where independent physicians in solo practice or groups of less than 5 deliver 87% of the care.

Big groups like Partners Health Care may help bring order but they may also create top-down bureaucracies that squelch innovation and creativity. Ask any doctor what fellow doctor they admire the most, and it is likely to be a creative diagnostician – not a faceless organizational bureaucrat. Lee and Mongan face this dilemma and others like it head on. They say ingrained medical cultures and mindsets resist change and that big organizations are unlikely to bring down costs. In Boston and Massachusetts, Partners Health is the most expensive act around, partly because it monopolizes care and can dictate its price.

The two physician executives say that while big organized integrated groups may be an improvement over independent physicians, they offer no panacea. According to the reviewer, “The future of medicine will continue to be defined by experimentation and a fitful groping towards improvement – a long, slow, grubby process not timed by five-year plans emanating out of Washington.”

The Lee and Mongan book reminds me of another book with “chaos’ in the title, From Chaos to Care; The Promise of Team-Based Medicine “ (Perseus Publishing, 2002@) by David Lawrence, MD, chairman emeritus of Kaiser Permanente. Both books share the same thesis, we would do much better is large systems replaced thousands of small practices. This view mirrors conventional Washington wisdom. If we only had more Mayos, Kaisers, and Partners dotting the landscape, costs would down 20%, salaried doctors wouldn’t have incentives to do more, care could be standardized, and outcomes would improve.

Which brings me to chaos theory. In 2008. Dr. Edward N. Lorenz, a meteorologist who sought to predict the weather with computers but instead ended up fathering chaos theory, died at 90 at his home in Cambridge, Massachusetts. Lorenz was best known for describing the “butterfly effect,” the idea that a small disturbance like a butterfly flapping its wings in Brazil could cause a tornado in Texas. The flapping wings represents a small change in the initial condition of a system. This causes a chain of events leading to large-scale phenomena. Had the butterfly not flapped its wings, the final system might have vastly differed.

Dr. Lorenz realized perfect weather forecasting was a fantasy. Perfect forecasting requires perfect knowledge of wind, temperature, humidity, and other conditions everywhere around the world at one moment of time. Even a small descrepancy could lead to completely different weather.

It is a fantasy that one can predict and completely control social consequences and behaviors with organizations or computers. The variables are simply too many. As chaos theorists say, “Small variations of the initial condition of a nonlinear dynamical system may produce large variations in the long term behavior of the system.

Reverse chaos theory may be at work here. Instead of the Washington tornado clipping the wings of patient and physician butterflies, the reverse may be true. Health care expectations – the wings of individual patients and independent doctors – may continue to cause the tornado in Washington.

Wednesday, October 21, 2009

Preface: This note appeared in Sermo.com, asking the 110,000 Sermo physicians to vote and express their concern about S.1776. which announces S.1776, repeals, SGR, and and fixes doctor Medicare reimbursement

Dear Sermo Physician,

I need your input on an issue being debated in Washington, DC this week: Medicare reimbursements to physicians. Late last week, the Senate leadership announced the Senate is likely to consider S. 1776, which repeals the sustainable growth rate (SGR) mechanism under Medicare.

As you may know, the SGR was created in 1997 with the idea of keeping costs under control. While cost-containment is a good goal, if the mechanism had functioned as designed, physicians would have seen Medicare reimbursement cuts in recent years. In fact, every year since 2004, it has literally required an Act of Congress to prevent Medicare reimbursement cuts under this mechanism. This will happen again this year, or else physicians will see a 21% cut at the end of this year.

There is broad bipartisan recognition that physicians cannot, must not, and will not see a 21% Medicare reimbursement cut at the end of the year. There is also bipartisan agreement that SGR is broken and needs to be repealed and replaced, so Congress need not provide patches each year. There are many, many varying ideas on what a "fix" should look like, and what should replace it.

The AMA and other medical groups are lobbying for S. 1776 as a fix to the SGR problem. I want to provide each of you a chance to speak for yourselves. Here are a few key facts to help you understand S. 1776:

This bill is separate from other proposed healthcare reform legislation in the Senate and the House.

This bill repeals, but does not replace the SGR. Instead, this bill freezes physician Medicare reimbursement rates with a 0% increase over the next decade. There is no guarantee of anything further and it does not address what happens after the ten years are up.

This bill adds over a quarter trillion dollars to the deficit with no offset. This bill is not paid for. To put this in perspective, this price tag amounts to over $5,600 dollars for every senior on Medicare right now. It is larger than all the government funding bills the Senate has considered this year - put together. This bill does not include any medical liability reform. One of the top concerns the Sermo community expressed to me in past weeks was the need for tort reform/med-mal reform.

As a physician, I firmly believe we deserve better than a one-sided "repeal" of the SGR, which is not "replaced" with something sustainable - and which also does not include tort reform. As a Senator, I am concerned about the fiscal responsibility of adding $250 billion to the deficit. The national debt is already at $11.8 trillion dollars, or over $38,000 per American, and I believe deficit spending and debt effectively steals from our children and grandchildren. Instead, we should be eliminating the estimated $300 billion of waste, fraud, and abuse each year in the federal government.

I want to know what you think is best for you as a physician. Please share with me your thoughts in the accompanying survey and comments below. I will take your input and use it in my conversations with my Senate colleagues. Thanks for your engagement on this issue.

It was Shakespeare who called Brutus' stabbing of Caesar as “the unkindness cut of all.”

Now senators of today are proclaiming the proposed SGR-based cut of 21%, scheduled for January 2010, and 4-5% more each year thereafter, e.g., 25% in 2011, as the modern equivalent of the Brutus stabbing.

A Medicare cut of this magnitude is unkind to patients in that it might cut off access of patients to doctors. Some 30% of Medicare patients are already having a hard time finding doctors. These cuts would worsen the situation.

The cut is unkind to doctors, too. Many primary care doctors are already struggling to make ends meet. The profession as a whole derives about 1/3 of their total income from Medicare, and the proportion is much higher among geriatricians, primary care doctors, and certain specialists – urologists, ophthalmologists, and oncologists.

If the cuts were to take place, physician polls indicate about 40% of doctors say they would retire, see fewer Medicare patients, or simply not accept new Medicare patients.

Now Medicare cuts have become a central issue in the health reform debate. The papers are full of news on the debate.

Take titles of news stories,

• October 21, “Senate Democrats Hit Snag with Doctor Payment Bill, ” New York Times

Under current law, Medicare doctors payment will fall by 21% next year. Nobody, Democrat or Republican, wants to let the cuts take effect. Congress has repeatedly blocked similar pay cuts. But permanently scrapping the planned cuts would add some $247 billion in federal spending over the next decade.

A Democratic bill ( S. 1776) would permanently scuttle cuts without addressing the higher cost. The would simply take the cuts out of the bill and handle it separately by adding to the deficit.

Republicans favor scrapping the pay cuts, but oppose the bill because it would add to the deficit. They would keep it in the bill, but find ways to pay for it.

Count Bob Corker, a Tennessee Republican said, “I absolutely agree that physicians around this country do not need to take a 25% cut.”

Corker also cited a report from The Hill that said Democratic leaders offered the AMA and other doctors’ groups a deal: The Democrats would block the Medicare pay cuts, if the doctors’ groups would back Democrats’ broader health-care bill. Corker compared the deal to prostitution,

Corker uncorked this message, “We all know that the selling of one’s body is one of the oldest businesses that has existed in the history of the world. And so the AMA now is engaged in basically selling the support of its body by throwing future generations under the bus by in essence urging that we as Congress pass this week a quarter of a trillion spending bill, unpaid for. And if we would do that we might get their support in health care reform."

The AMA denied this charge and Senators ought to vote for S. 1776 before access to care for patients is further eroded by steep Medicare cuts to physicians.

Latest news? Senate Democrats have backed down. They will not cancel doctor cuts without finding a way to pay for it, e.g. to offset costs. Stay tuned.

Tuesday, October 20, 2009

I would like to introduce you a remarkable article by Edward J. Volpintesta, MD, a 65year old solo primary care doctor in Bethel, Connecticut. Dr. Volpintesta is a veritable writing machine and has been published in the Wall Street Journal, the New York Times, medical journals, and other publications. His articles cry for a deeper understanding of primary care dilemmas.

A “Typical Day” in the Office

In the October issue of Connecticut Medicine, Dr. Volpintesta hits the primary care dilemma on the head by simply recording a “typical day” in his office, in this case, a “half-day,” lasting 9 hours. The power of his entry is the simple recording of events of his day – including details of 7 office visits, 9 telephone conversations, and reviewing, signing, or taking care of some 25 documents, faxes, referrals, and other paperwork.

What struck me about his chronicle is how many of his activities were non-reimbursable. In Denmark and other countries, these activities tend to be reimbursed through a combination of management fees for serving a patient panel, fees for responding to telephone calls and emails, and fee for-service during office visits. Not being paid for telephone calls, which can take up to 1/3 of a doctor’s time, is a particularly egregious example of what should be paid for any reform measure to have impact in the clinical trenches.

Keep in mind doctors like Dr. Volpintesta are the workhorses of our health care delivery system. These physicians , which deliver most of initial care in this country, are generally in independent practice, are underpaid compared to specialist peers, represent a threatened species, and are short by 50,000 doctors, scheduled to reach 160,000 in a decade.

I have long maintained pundits like myself and health reformers in Washington should spend a day in the office of busy solo practitioner. Only then can we begin to appreciate travails of primary care – the hours spent on such non-reimbursable activities as paperwork, phone calls, and prescription writing and renewals.

These activities require knowledge possessed only by the physician. In my opinion, these activities, because of the time and know-how required, ought to be reimbursed. That would make primary care more rewarding and would close the satisfaction and monetary gap between primary care and specialty care.

Two golden rules for writing are:

One, if you have a nail to hit, hit it on the head.

Two, be concrete, not abstract.

The health reform nail I’ve been hitting in my book and frequent blogs is this: the next big health reform crisis will be lack of access to primary care physicians.In the concrete, this will occur when 78 million baby boomers turn 65 in 2011, and, if and when, Obamacare reforms propel 25 to 30 million uninsured into the market in 2012 or thereabout.

Primary care doctors, already overworked, will be swamped, and waiting times to see doctors will escalate. Waiting have already grown to twice to three times the national average in Massachusetts, now 3 years into its universal coverage plan.

Proposals and Events on Ground Designed to Close Primary Care Gap

• Expanding medical schools to produce more primary care doctors.

• Increasing the number of primary care residencies.

• Instituting payment reform by paying primary care doctors 10% more and narrowing the gap between what Medicare pays primary care and other specialists.

• Doing away with “fee-for-service” for primary care, specialty care, and hospital care so “accountable care organizations” can deliver budgeted or capitated care, now being considered in Massachusetts.

• Pushing widespread development of more “integrated group practices” with hospitals, primary care doctors, and specialists acting in tandem, as in now done in 15 or so large megaclinics, such as Mayo, the Cleveland Clinic, Kaiser, and Geisinger.

• Incentivizing and rewarding doctors and hospitals to install ubiquitous electronic medical records, and by so doing, systematizing care through standardized protocols complying with comparative research effectiveness results and creating more effective virtually integrated groups

Two Primary Care “Donut Holes”

These approaches have virtues, but they have three gaping reform holes:

• One. How to fill the “ primary care donut hole, “ namely, between now and the 10 years it takes to produce a newly-minted primary care physician.

• Two, How to pay for the many “non-reimbursable” activities that primary care physicians must endure.

• Three, how to address the needs of “independent” physicians in private practice, who comprise at least 80% of doctors providing care on the frontlines.

Until pay is increased for present “independent” primary care doctors through commonsensical reforms and working conditions of these doctors is understood, the primary care shortage is unlikely to be alleviated, and expansion of access will be a pipe dream.

Dr. Richard Reece is author, blogger, speaker, and innovation and reform commentator. Dr. Reece’s latest book, Obama, Doctors, and Health Reform (IUniverse.com) is available at amazon.com and barnesandnoble.com. His blog is www.medinnovationblog.blogspot.com

Sunday, October 18, 2009

“I have met the enemy, and he is us.” Pogo’s words describe the health care fuss - a veritable food fight among blunderbusses. The issues are: What's the best direction? How do we prevent defection?

As of now, Democrats are blaming each other on how to find the right solution, on how to execute the health care revolution, on how to extend coverage and rein in costs, while avoiding grievous political losses, lifting premiums for the masses, raising taxes on the middle classes, offending their friends in labor, upsetting their favorite liberal neighbor, offering a public option, while saying with a straight face it’s not a government co-option, and in the process, possibly bringing down all of the House, and one-third of the Senate without looking like a louse.

Pogoscenti among Democrats are saying of their spats: there's desperation to the right of us, disaffection in the center of us, and disillusionment to the left of us. It comes down to open combat, about who in November 2010 is at-bat. It’s about Blue Dogs, against those in purple liberal Togs. It’s about taxing Cadillac plans, rather than the “rich” with money on their hands. In the end, it will be about settling disputes that loom, with a fellow named Obama in the room.

Preface: In my book, Obama, Doctors, and Health Reform (IUniverse, 2009), I devote several chapters to the work of Paul Grundy, MD, Director of Healthcare, Technology and Strategic Initiatives at IBM Global. Paul believes Medical Homes can transform American health care by transferring most care from specialists and hospitals back to primary care doctors practicing in “medical homes.” In the process, this transformation may “shutter” many acute care hospital – a dubious proposition in my opinion. Nevertheless, Paul’s ideas are sound and are now being set in motion in 100 demonstration projects across the U.S.

Here I reprint an October 17 blog on Grundy’s work by David Harlow, a health care lawyer and consultant who blogs at HealthBlawg.

Dr. Paul Grundy is on a mission — a mission to promote the patient-centered medical home model that he has been instrumental in developing and rolling out, in his dual role as Director of Healthcare, Technology and Strategic initiatives for IBM Global Wellbeing Services and Health Benefits, and President of the Patient-Centered Primary Care Collaborative.

I had the opportunity to speak with him last month (here’s the transcript and podcast), at the end of a day he spent in Washington, D.C., hard at work on this continuing mission.

I use the word mission because Paul frames the need for dissemination of the medical home model in terms of a transformational change in the nature of the covenant between doctor and patient — not simply a reformation. In his view, reformation without transformation creates as many problems as it solves: e.g., the primary care shortage exacerbated by increased insurance of the population at large in places like Massachusetts.

The Patient-Centered Medical Home model — described more fully in materials from the Patient-Centered Primary Care Collaborative, and TransforMED, an affiliate of the American Academy of Family Physicians — relies on a shift in physician compensation from a fee-for-service focus to a patient management focus; from an episodic focus to comprehensive, relationship-based care.

It’s been implemented in over 100 pilots around the country. Denmark learned about the model here in the U.S. decades ago and has implemented it fully across the country’s health care system, shuttering most of the acute care hospitals in the country in the process. Pilots in the U.S. include Geisinger’s, which Grundy says has been remarkably successful, yielding an ROI of over 250%, including a 12% reduction in ER utilization, a 20% reduction in hospitalization, and a 48% reduction in rehospitalization.

Technology is an important part of these efforts and savings. Even given the potential high cost of technological solutions and Health 2.0 tools, the costs pale in comparison to the $1 million-a-bed cost of hospital construction, let alone hospital staffing and other operating costs.

The key to catching up with places like Denmark and Spain, and systems like Geisinger, Intermountain and the VA, says Grundy, is the recognition and implementation of medical home-compatible payment systems by CMS, since it controls half of the country’s health care spend, and providers march to CMS’s tune. Without that buy-in, it has been difficult to promote the model beyond integrated delivery systems, large group practices, and pilot-project-funded solo and small practices.CMS announced Medicare funding for medical home program demonstrations in the states the day after Paul was in Washington last month — coincidence? I think not! — and the concept is built into legislation percolating its way through Congress.

The model is a critical component of future improvements to our health care system; Paul Grundy and the patient-centered medical home both deserve our close attention.

Until you walk in another man’s moccasins, you can’t imagine the smell.

Robert Byrne, 1928 - , American Chess master

Preface: The October issue of Connecticut Medicine contained a remarkable article by Edward J. Volpintesta, a 65 year old solo family physician in Bethel, Connecticut. The article is a diary of the day of a primary care doctor – from start at 7:15 A.M. to finish at 4PM.

I reprint it because I have long maintained pundits like myself and health reformers in Washington should spend a day in the office of busy solo practitioner. Only then would we begin to appreciate the travails of primary care – the hours spent on such non-reimbursable activities as paperwork, phone calls, and prescription writing and renewals.

These activities require knowledge possessed only by the physician. In my opinion, these activities, because of the time and know-how required, ought to be reimbursed. In one fell swoop, that would make primary care more rewarding and would close the satisfaction and monetary gap between primary care and specialty care.

A reprint of the full article follows.

A Portrait of the Primary-Care Physician at Age 65

Edward J. Volpintesta, MD,

Connecticut Medicine, October, 2009, pages 559-560Health information technology and other electronic assistance will do little to change the heart and soul of primary care.

Explaining the illness, its prognosis, and alleviating the fears that go along with it are time and energy-intensive. Dealing with a sudden death or a complication of a medication, or social ills like divorce or a child hooked on drugs, or how to deal with an aging and needy parent are a few examples of what primary care doctors do.To exemplify this I have described a “typical” day in my office.

1. In office at 7:15 are. Spend 35 minutes collating fax reports that collected during the night and deciding which need immediate attention that day (nine lab and imaging reports, two visiting nurse reports that needed review and signature and return; for prescription renewals from pharmacies; one request of records form insurers, one nursing home discharge from to be reviewed and signed and returned, and one emergency room record).

2. Death certificate filled out form patient who died suddenly over weekend. Called family and explained probable cause of death and offered condolences (several minutes).

3. Filled out four fax forms for refill of medical to local pharmacy.

4. Telephone conversation (sever minutes) with patient who recently was found to have a mass in left upper abdomen noted incidentally on CAT scan of chest done by pulmonologists looking for cause of chronic cough. I discussed with him and ordered CAT of abdomen and pelvis. Phoned in prescription for premedication with steroids because of hazel nut allergy.

5. Telephone conversation (several minutes) with patient regarding abnormal CAT-PET scan of lesion of left lung. Wants to get a medical center in New York City. Long discussion explaining that this problem could be handled locally.

6. Telephone conversation with patient regarding his need for a prescription to be phoned to mail-order pharmacy. He gave me fax number which didn’t work because it was really a phone number. Called him back to clear up problem.

7. Telephone conversation with patient recently started on insulin. Called me to say that sugar is over 300 before breakfast. Brief discussion with her. Insulin increased. Told her to call me back with prelaunch glucose value.

8. Telephone conversation with patient with history of diverticulitis. Has what she thinks is another attack. She called here gastroenterologist but he was on vacation. Told her to come in immediately to see me.

9. Office visit. Patient with otitis media treated several days ago. Got worse over weekend and went to emergency room. She was very concerned because worked as receptionist in hotel and couldn’t hear well. Wanted to see ENT specialists. I called the specialist but the voice mail was not working properly... Finally go thorough on fifth try. Patient as elderly and I had spent several minutes explaining how to get to ENT office. I drew a map for here. In the meantime she suddenly started crying about how her life had been hard since her husband died and told me of sad and frightening experiences she had while working in a bank.

10. Telephone conversation with daughter of patient whose elderly father had been to ER complaining of fatigue. Had been in office a few days ago and inconclusive Lyme tests; that done in the ER were diagnostic. Was supposed to have a stress test today but daughter concerned that he is too weak to do it. Test cancelled.

11. Office visit. Patient with bacterial elbow bursitis. Seen in ER few days ago and given I.V. antibiotic. Gett6ign worse. I set up infectious disease consult.

12. Telephone conversation. Dialysis patient’s wife called to discuss his A1C.changed medication. Wife upset because patient smoking more than pack of cigarettes a day. Told her I would speak to him.

14. Office visit. Patient seen in follow-up for depression. Sees a psychologist who told her to see me for medication for break-through panic attacks.

15. Office visit. Patient seen for neck pain. Afte4r he leaves comes back 10 minutes later asking me to look at area on face that he scratched and had bled.

16. Office visit. Elderly patient comes in after having seen a chiropractor for back pain. Is sobbing. Has been depressed and is self-mediating with pain medication. Has seen psychiatrist in the past but has stopped because he feels he wasn’t being help. I call wife and arrange for crisis intervention at hospital. I write down list of his cardiac medications for him and wife who accompanies him to take to hospital. Patient is admitted for psychiatric care.

17. Office visit. Sutures removed from patient’s chin.

18. Office visit. Patient seen in follow-up for hypertension.

19. Office visit. Patient seen for tracheitis.

20. Telephone conversation with patient. Had some antibiotic left who has lung mass (item 4). Very upset. Crying. Wants to go to center in New York City for care. She was waiting to hear form pulmonary consultant who I had called earlier for a consult. I called him again and was told that he got my message and would call her.

21. Telephone conversation. Patient has cystitis symptoms. Had some antibiotic left over from previous infection? Already took a few. I phoned in some more. Told here to follow up with me.

I finished by day at 4 pm. When I arrived home, I received a call from a patient with a toothache. Her dentist would see her tomorrow but wouldn’t order pain medication until he saw here. So I phoned an analgesic to a local pharmacy.

I did not receive any phone calls for the rest of the evening.

In some cases the telephone conversations were more time-consuming and challenging than the office visits. When I started my practice 35 years ago, I would see about 35 patients in a full day and about half that number on my half days. I occasionally make hospital and nursing home visits but not regularly. I use hospitalists and delegated nursing home care as well.

Clearly, a new paradigm of primary care is evolving. Attending to patients’ social and psychological needs and the many administrative details that compete for primary-care doctors’ attention has become almost overwhelming. My method of changing to keep up with modern medicine is to keep my patient load low, about 15 patients on a full day (three days a week) and seven or eight on a half day (two days a week).

This approach allows me to maintain my equanimity. It’s the only ways that can come even halfway close to bang the physician I want to be.

Other physicians’ days will be more or less complicated in proportion to their abilities, their ages, their financial goals, and the lifestyle that they desire.It would be informative to know what other primary care doctors’ days in the office and elsewhere are like.

Saturday, October 17, 2009

Robert Laszewski, a trusted inside-the-Beltway political consultant, has concluded we will “almost certainly not” get a health bill this year.

Laszewki says three powerful contradictory forces made him come to this conclusion.

• One, on the upside for passage, Democrats are absolutely committed to producing a bill. They are desperate. If they do not, they are likely to lose the House in November 2010 and maybe in the presidency in 2012. Obama’s whole domestic agenda rides on getting a health reform bill in 2009. Keep in mind Congressional approval rating are noW 21%. Ironically, the odds for passage may rest in the hands of a Republican Senator, Olympia Snowe, who is opposed to th Democrat's most cherished prize – the public option - which could be ultimate gateway to single-payer. SomeDemocrats are in a mood of quiet desperation.

• Two, on the downside for passage, are the American public – who are anxious about losing their current private plans and Medicare benefits, as shown by the town halls, tea parties, and the polls. The public is not convinced Obamacare will benefit them persibally or improve the quality of thier care. Obama’s approval on health care handling is in the low forties, and his disapproval is in the mid-fifties. The public is not buying the argument you can expand coverage to 25million uninsured, subsidize those below the poverty line, cut Medicare by $500 billion, stamp out fraud, abuse and waste, and tax health plans, drug companies, device makers, and others without these companies passing along increased prices to them - the middle class.

• Three, there's another downside, and it’s a big one. Democrats don’t have a bill yet. To make matters worse, the jerry-rigged Obama coalition – built behind closed White House doors – has suddenly gone wobbly. AHIP (America Health Insurance Plan) and the Blue Cross Association fired a warning shot by accouncing commissioned studies showing Obamacare would double premiums over the next 10 years by $4000 per family of 4 per year. AMA members, furious that the Senate Finance Committee, only suspended Medicare doctor pay cuts for one year, to be followed by a 25% cut the next year, are in open revolt and will say so in their annual November Houston meeting. The AFL-CIO, and other unions, bitterly oppose taxes on “Cadillac health plans,” which cover many of their members. The Chamber of Commerce, representing small business, is running TV ads attacking Democrat proposals. State governors, Democrats as well as Republicans, say their budgets will not withstand expanded Medicaid benefits. Blue Dog Democrats, up for re-election in many affluent districts, fear more taxes on the “rich” will destroy their chances for re-election.

Put it all together, and what have you got?

You’ve got a recipe for probable bipartisan political failure when you go to the floor for a final vote .

You’ve got the makings of a political disaster that frightens even the most optimistic Democratic forecaster.

You’ve got a fascinating intraparty battle to head off a possible political death rattle.

You’ve got an expansion problem of raising $500 billion to pay for expanding access without expanding taxes, without expanding your list of political enemies, without expanding the federal debt.

You've got eight legislative procsses to worm through, each laden with political landmines, to reach your objective on the biggest piece of legislation since Social Security and Medicare.

Friday, October 16, 2009

Prelude: To doctors the SGR formula is a symbol of their political impotence. The following is from the Wall Street Health Care Blog.

By Jacob Goldstein

“A bill introduced in the Senate this week would block the 21% Medicare pay cut for doctors scheduled to take effect for doctors next year. Blocking the cut would increase the government’s costs by more than $200 billion over the course of a decade.”

“Loyal Health Blog readers know all too much about the sustainable growth rate, the mechanism Congress adopted in the 1990s to try to ensure that the amount the Medicare pays for annual doctor care of each beneficiary doesn’t grow faster than the overall economy.”

“Obviously, it didn’t work. Doctor costs per beneficiary have shot up along with the rest of health care spending. Under SGR, when overall spending on doctor care increases in this way, the amount doctors get paid for each service is supposed to go down. But Congress has intervened time and again to block cuts that were supposed to take effect under SGR.”

“The health-overhaul bill introduced in the House would scrap the existing SGR formula. The Senate Finance bill blocks the pay cuts for next year but leaves SGR in place, which means the pay cut would be back in 2011. “

“So this week Sen. Debbie Stabenow, a Michigan Dem, introduced a bill in the Senate (S.1776) to get rid of the existing SGR formula. Because of some procedural hocus pocus, it may go straight to the Senate floor without going through a committee.”“The AMA, which supported the House health bill, said today it’s launching TV ads to support the Stabenow bill.”

“Meanwhile, Dow Jones Newswires reports, Senate Minority Leader Mitch McConnell said today that Republicans will offer amendments to offset the cost of the bill. He argued that the bill was introduced separately from the Senate Finance committee’s big health-care bill as an accounting trick, to keep the costs of the broader bill below $900 billion.”

And so the saga for cutting doctors’ annual Medicare pay goes on. In the House, the SRG is to be forgotten, in the Senate it is not gone. The House would eliminate the failed SRG formula completely, The Senate would drop it for a year, then reinstate it discretely. To Congress it appears doctors are nothing but a financial pawn. Still Congress fears a widespread doctor shortage. This could lead to political short circuit, even a genuine electoral outage. Doctors deserting Medicare due to low pay hangs like the sword of Damocles. Legislators fear loss of medical expertise, perhaps even a physician stoppage.

A: Because of something I read. John Goodman, the conservative economist at the National Center of Policy Analysis, says when it comes to health care, everybody’s IQ automatically drops by one standard deviation, all reason goes out the window, everyone should pay the same premium rather sick or well, young or old, and no one knows what things cost.

According to Goodman, “ We do not as a rule find this attitude in the market for other important goods. For example, most of us think people should pay the market price for the food they eat, the clothes they wear, and the house they live in. We also don’t seem to have a problem with people paying market prices for life insurance or disability insurance.”

Health reform, therefore, is for dummies.

Q: Why is that?

A: Because people think of health care as a religion. This is true on the left, but on the right as well. Health care is a social good. It is not about money but about being good.

Q: So why do the left and right disagree on the public option?

A: Because the left thinks of health care as a government religion, as the good at the top stamping out the bad at the bottom, and the right thinks of health care as the private business of doing well while doing good.

Q: What’s so bad about that?

A: Nothing. It’s simply the Goodist and the Badist philosophies.

Q: Who are Goodists?

A: Goodists believe all conflict stems from avoidable misunderstanding. Goodists think that the world's evils spring from an insatiable quest for profits, and technologies, systems, complexes (as in "medical -industrial") required to maintain profits. Anything that does not spring from the hearts of men, where love abides, is bad.

Goodists confuse wishes for possibilities. Goodists put a higher premium on their own moral intentions than on the efficacy of their actions. Forget the consequences. Goodists champion education and good will and other people’s money as the solution, whatever the problem.

Above all, Goodists like to be seen to be good. Big Government is Good Government when Goodists run it.

Q: But doesn’t that make conservatives “Badists”? After all, conservatives regard health care as a business. That requires margins to carry out one’s mission. No margin, no mission.

A: Exactly. To Goodists, conservatives are Badists because they are realists rather than idealists. Take the conservative attitude towards the concept of a single payer system Conservatives know any open-ended government entitlement leads to unfunded mandates, which even now approach $50 trillion. And not only do conservative detest unfunded mandates, but mandates that restrict the freedom of individuals and employers.

Q: But doesn’t Big Government help bring everybody in line for the common good and the health of the people?

A: It depends on your point of view.

If you are a Badist, you maintain the health system is only responsible for 15% of a nation’s health. The rest is due to culture, social cohesion, sanitary conditions, and economic prosperity.

If you are a Goodist, the health system is solely responsible for a nation’s overall health and longevity. Single payer is good because everybody is equal, even though some are more equal, e.g., politicians and government bureaucrats, than others, the public and health providers.

Goodists maintain when it comes to the national health, money is no object. Social equity is the goal. Let no one, especially those driven by money, rise above the common herd.

Q: But aren’t equity for all and money is no object two of the reasons why Medicare is going broke?

A: Exactly, but witha government religion, money is no object. Power and belief are. Consider the political calculus. In any given population, 90% of voters are well, and 10% are sick. If those who are well perceive health care to be “free,” i.e. involves other people’s money not yours, you will vote for the Goodists. The majority depend on you. The sick are in the minority. The minority are marginal as a voting bloc, and the expense of their care can always be minimized by paying doctors or hospitals less or by disallowing payment for expensive procedures and for those near the end of life. Single payer is wonderful when you are well, not so good when you are very sick or very old.

Q: So “health care” is more important than “sick care.” But isn’t that a paradox? Isn’t medicine supposed to be about caring for the sick?

A: Yes, there’s a paradox. Goodists lose money on the sick. Badists make money out of health and wellness. How? They select the youngest and healthiest populations to cover because that’s where the profit is, and deny or restrict care to those with pre-existing illness. That way the premiums are coming in, but little money is going out. Meanwhile Medicare and Medicaid are taking care of the old and the sick. It’s cherry picking versus bury picking.

Q: But that must create conflict between the Goodists and the Badists? And that must make health reform difficult?

A: Exactly. As Uwe Reinhardt, the always colorful Princeton health economist observed, health reform is difficult because various factions of the profit-gouging health care industry are like Afghan warlords. They make money in their enclaves. When threatened, they retreat to safe havens, and when those havens are threatened, they open fire on the enemies of the status quo.Q: Thank you for enlightening me.

Thursday, October 15, 2009

I don’t mean to sound like a broken record, but for the record, I shall.

I have long maintained - in my book Obama, Doctors, and Health Reform and in previous blogs - that increased coverage without more doctors is meaningless and that the next big crisis will be lack of access to doctors.

Why? Because there will be no doctors there. To praphrase Gertrude Stein’s, “There will be no there there.”

This crisis will come to a head when 78 million baby boomers begin to join Medicare in 2011, or if 25 million now uninsured get coverage and start seeking doctors. This crisis is already being played out in Massachusetts, where waiting times to see primary care doctors are now two to three times the national average.

Where will the doctors come from? Beats me. The American Academy of Family Physicians predicts we will soon be 40,000 primary care doctors short. Worse yet, the overall shortage of doctors will climb to nearly 160,000 by 2025, according to the Association of American Medical Colleges.

The House and Senate overhaul bills are anemic in addressing the problem. They offer a 10 percent bonus for primary care doctors over five years, will marginally increase Medicare payment rates, and will redistribute about 1,000 unfilled residency positions to teaching hospitals that commit to creating more primary care residencies. This is unlikely to impress medical students, who know that specialists make twice the income in half the time as primary care doctors.

Congress seems unmoved by the shortage. A proposal backed by Senate Majority Leader Harry Reid, D-Nev., and the teaching hospital lobby to add 15,000 Medicare-funded medical residency positions -- a 15 percent increase that would favor more primary care training -- was considered dead on arrival because of its $10 billion price tag over a decade.

Dr. Darrell Kirch, CEO of the Association of American Medical Colleges, said extra training slots for primary care amount to a “drop in the bucket.” He noted that after Massachusetts in 2006 required all citizens to have health insurance, the demand for care quickly overwhelmed the state's doctors. "It’s a huge issue that concerns us greatly," says Kirch, whose association represents all 130 medical schools and nearly 400 major teaching hospitals.

Ken Raske, president of the Greater New York Hospital Association. Giving millions of Americans health insurance, while not increasing the doctor supply is a recipe for trouble in his view. And Deval Patrick, Massachusetts governor, has said, “Coverage without access is meaningless.”

The Health Reform Maze

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Book Description: In this first book in a series of four, Richard L. Reece, MD. provides a unique view of the roll out, and run up, of the Affordable Care Act. Reece shows in this book the progress and facets of ObamaCare's marketers and messengers, as the day approached for the launch of health insurance exchanges - the single most public and problematic portion of the new law. This is a must read for anyone who wants to chronicle this attempt to organize more than one-sixth of the U.S. economy by adding layers of federal government control and regulations.

Reece has been writing about U.S. health care for more than 45 years. His knowledge and experience, added to his keen intellect and gift of subtle humor, make this book a valuable part of anyone's collection.